- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.16 / $1,274.11 / $2,966.49
| Professional | | $546.16 | $1,274.11 | $2,966.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.12 / $1,028.74 / $1,028.74
| Professional | | $1,022.12 | $1,028.74 | $1,028.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.96 / $1,623.88 / $2,319.83
| Professional | | $1,360.96 | $1,623.88 | $2,319.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.65 / $771.56 / $1,138.52
| Professional | | $696.65 | $771.56 | $1,138.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.09 / $1,150.09 / $1,314.57
| Professional | | $1,150.09 | $1,150.09 | $1,314.57 |